Abstract
Objective
To compare the effects of 2 different injection sites of low doses of botulinum toxin
type A with steroid in treating lateral epicondylalgia.
Design
Double-blind, randomized, active drug-controlled trial.
Setting
Tertiary medical center.
Participants
Patients with lateral epicondylalgia for >6 months were recruited from a hospital-based
outpatient population (N=26). A total of 66 patients were approached, and 40 were
excluded. No participant withdrew because of adverse effects.
Interventions
Patients were randomly assigned into 3 groups: (1) botulinum toxin epic group (n=8),
who received 20U of botulinum toxin injection into the lateral epicondyle; (2) botulinum
toxin tend group (n=7), who received 20U of botulinum toxin injected into tender points
of muscles; and (3) steroid group (n=11), who received 40mg of triamcinolone acetonide
injected into the lateral epicondyle.
Main Outcome Measures
A visual analog scale, a dynamometer, and the Patient-Rated Tennis Elbow Evaluation
were used to evaluate the perception of pain, maximal grip strength, and functional
status, respectively. Outcome measures were assessed before intervention and at 4,
8, 12, and 16 weeks after treatment. The primary outcome measure was a visual analog
scale.
Results
At 4 weeks after injection, the steroid group was superior to the botulinum toxin
tend group in improvement on the visual analog scale (P=.006), grip strength (P=.03), and Patient-Rated Tennis Elbow Evaluation (P=.02). However, these differences were not observed at the 8-, 12-, and 16-week follow-up
assessments. There was no significant difference between the steroid and botulinum
toxin epic groups.
Conclusions
Injections with botulinum toxin and steroid effectively reduced pain and improved
upper limb function in patients with lateral epicondylalgia for at least 16 weeks.
The onset of effect was earlier in the steroid and botulinum toxin epic groups than
in the botulinum toxin tend group.
Keywords
List of abbreviations:
BoNT (botulinum neurotoxin), BoNT-A (botulinum toxin type A), PRTEE (Patient-Rated Tennis Elbow Evaluation), RCT (randomized controlled trial), VAS (visual analog scale)To read this article in full you will need to make a payment
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References
- Prevalence and determinants of lateral and medial epicondylitis: a population study.Am J Epidemiol. 2006; 164: 1065-1074
- Epidemiologic surveillance of upper-extremity musculoskeletal disorders in the working population.Arthritis Rheum. 2006; 55: 765-778
- Joint capsule attachment to the extensor carpi radialis brevis origin: an anatomical study with possible implications regarding the etiology of lateral epicondylitis.J Hand Surg Am. 2014; 39: 219-225
- Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials.Am J Sports Med. 2013; 41: 1435-1446
- Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials.Lancet. 2010; 376: 1751-1767
- Treatment of refractory pain with botulinum toxins–an evidence-based review.Pain Med. 2011; 12: 1594-1606
- Injection of botulinum toxin for treatment of chronic lateral epicondylitis: systematic review and meta-analysis.Semin Arthritis Rheum. 2011; 40: 532-538
- Injection of botulinum toxin for treatment of chronic lateral epicondylitis: systematic review and meta-analysis.Semin Arthritis Rheum. 2011; 40: 585-587
- Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial.JAMA. 2013; 309: 461-469
- Botulinum toxin type A for control of drooling in Asian patients with cerebral palsy.Neurology. 2008; 70: 316-318
- Therapeutic uses of botulinum toxin.N Engl J Med. 1991; 324: 1186-1194
- Effectiveness of botulinum toxin for shoulder pain treatment: a systematic review and meta-analysis.Arch Phys Med Rehabil. 2015; 96: 2214-2220
- Treatment of chronic tennis elbow with botulinum toxin.Lancet. 1997; 349: 1746
- Botulinum toxin injection versus surgical treatment for tennis elbow: a randomized pilot study.Clin Orthop Relat Res. 2002; 401: 125-131
- Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial.Ann Intern Med. 2005; 143: 793-797
- The myriad uses of botulinum toxin.Ann Intern Med. 2005; 143: 838-839
- Botulinum toxin-A treatment reduces human mechanical pain sensitivity and mechanotransduction.Ann Neurol. 2014; 75: 591-596
- Botulinum toxin type A selectivity for certain types of pain is associated with capsaicin-sensitive neurons.Pain. 2014; 155: 1516-1526
- TNFα induces co-trafficking of TRPV1/TRPA1 in VAMP1-containing vesicles to the plasmalemma via Munc18-1/syntaxin1/SNAP-25 mediated fusion.Sci Rep. 2016; 6: 21226
- Botulinum toxin as a pain killer: players and actions in antinociception.Toxins (Basel). 2015; 7: 2435-2453
- Behavioral and immunohistochemical evidence for central antinociceptive activity of botulinum toxin A.Neuroscience. 2011; 186: 201-207
- A novel molecular mechanism to account for the action of botulinum toxin against lateral epicondylitis.Int J Rheum Dis. 2008; 11: 83-84
- Botulinum toxin injection in the treatment of tennis elbow. A double-blind, randomized, controlled, pilot study.J Bone Joint Surg Am. 2005; 87: 503-507
- Treatment of chronic radial epicondylitis with botulinum toxin A. A double-blind, placebo-controlled, randomized multicenter study.J Bone Joint Surg Am. 2007; 89: 255-260
- Comparison between botulinum toxin and corticosteroid injection in the treatment of acute and subacute tennis elbow: a prospective, randomized, double-blind, active drug-controlled pilot study.Am J Phys Med Rehabil. 2010; 89: 653-659
- The Southampton examination schedule for the diagnosis of musculoskeletal disorders of the upper limb.Ann Rheum Dis. 2000; 59: 5-11
- Botulinum toxin type A products are not interchangeable: a review of the evidence.Biologics. 2014; 8: 227-241
- Conversion ratio between Dysport and Botox in clinical practice: an overview of available evidence.Neurol Sci. 2013; 34: 1043-1048
- Graphic representation of pain.Pain. 1976; 2: 175-184
- Interobserver reproducibility of the assessment of severity of complaints, grip strength, and pressure pain threshold in patients with lateral epicondylitis.Arch Phys Med Rehabil. 2002; 83: 1145-1150
- Associations between pain, grip strength, and manual tests in the treatment evaluation of chronic tennis elbow.Clin J Pain. 2002; 18: 164-170
- Reliability of Hong Kong Chinese version of the Patient-rated Forearm Evaluation Questionnaire for lateral epicondylitis.Hong Kong Med J. 2004; 10: 172-177
- Effect size estimates: current use, calculations, and interpretation.J Exp Psychol Gen. 2012; 141: 2-18
- Denervation of the lateral humeral epicondyle for treatment of chronic lateral epicondylitis.J Hand Surg Am. 2013; 38: 344-349
Article info
Publication history
Published online: September 22, 2016
Footnotes
Supported by the National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (grant nos. NCKUH-10407018 and NCKUH-10103018).
Clinical Trial Registration No.: NCT02767635.
Disclosures: none.
Identification
Copyright
© 2016 by the American Congress of Rehabilitation Medicine
